Kentucky CancerLink Colon Cancer Screening Form
Phone: 859-309-1700 Fax: 859-368-8418
Patient Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Zip code
*
County
*
Email
example@example.com
Race/Ethnicity
*
Please Select
White/Non-Hispanic
Hispanic/Latino
Black/African American
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native
Pacific Islander
Sex
*
Male
Female
Language Note
English Speaking
Spanish Speaking Only
Other
Birth Date MMDDYYYY
*
/
Month
/
Day
Year
Date
Last 4 of Social Security Number
*
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Okay to Leave Messages on Phone
*
Yes
No
I have Insurance
*
Yes
No
Primary Insurance
*
Medicaid
Medicare
WellCare
Other
Secondary Insurance
Medicaid
Medicare
WellCare
Other
Emergency Contact Name
Emergency Contact Phone
Relationship to Patient
Number In Household
*
Annual Household Income
*
max $46,950 (my be higher with dependents)
Smoking History?
*
Current Smoker
Never
Previous Smoker
Interested in quitting?
Yes
No
HOW CAN WE HELP YOU?
I need a..
FREE Colonoscopy (has insurance and income eligibility requirements)
FREE Cologuard (ages 45-74, average risk ie. no symptoms or family history of colon cancer, as well as insurance and income eligibility requirements)
Submit
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